Article

RTS and RTS-A have equal value in mortality prediction of patients with severely trauma

332 Correspondence / American Journal of Emergency Medicine 36 (2018) 319338

ChiCTR Chinese Clinical Trial Register SSC surviving sepsis campaign

Declarations

Ethical approval and consent to participate: Not applicable.

Consent for publication: Not applicable.

Availability of supporting data: Not applicable.

Competing interests

The authors declare that they have no competing interests.

Funding

YY was supported by a grant from Guangdong Provincial Depart- ment of Science and Technology (Grant number: 2015A020210093). JL was funded by a grant from the Traditional Chinese Medicine (TCM) Guideline for Preventing and Treating Sepsis group: (fund number: SATCM-2014-BZ (182)), which was supported by the State Administra- tion of Traditional Chinese Medicine of the P.R.C. (SATCM). The funding sources had no role in the preparation, drafting, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Acknowledgements

None.

Xianshi Zhou, MD* Zhongde, Zhang, MD

Jun, Li, MD Ye Ye, MD

Guanghua Tang, PhD Banghan Ding, PhD

Emergency Department, Guangdong Provincial Hospital of Chinese Medicine, affiliated to Guangzhou University of Chinese Medicine,

Guangzhou 510120, China

*Corresponding author at: Emergency Department, Guangdong Provin- cial Hospital of Chinese Medicine, 111 Dade Road, Yuexiu District,

Guangzhou 510120, China.

E-mail address: [email protected] (X. Zhou)

RTS and RTS-A have equal value in Mortality prediction of patients with severely trauma

To the Editor,

The article by Seong Chun Kim et al. is really interesting [1]. We agree that serum albumin is indeed important for trauma patients. While serum albumin is one of the most available biomarkers world- wide, and is almost always included in initial routine work-up for major trauma [2], it is easy for us to get this parameter on trauma patients.

As a suggestion, Seong et al. concluded that RTS plus serum albumin (RTS-A) performed better than RTS in predicting the in-hospital mortal- ity of trauma patients. But the author enrolled patients regardless of the severity of trauma and the average of ISS score is 9. We have a hypoth- esis that RTS-A performed in patients with severe trauma (ISS >= 16) as good as in patients with mild trauma. We would like to use our severe trauma (ISS >= 16) data in order to validate the Discriminatory power of RTS-A.

This is a retrospective analysis. We collected patients with se- verely trauma (ISS >= 16) admitted to West China Hospital of Sichuan University from May 1st, 2016 to August 31th, 2016. A total of 9 var- iables were collected for this analysis including age, sex, systolic blood pressure (SBP), respiratory rate (RR), PTpercent, PTINR, base excess , serum albumin, GCS, ISS score. The missing values in- cluded the PTINR (8%), PTpercent (8%), albumin (5.3%). Then we cal- culated RTS, RTS-A, BIG and EMTRAS for every patient, which was similar with Seong.

Firstly, a univariate analysis was conducted using all the variables (age, sex, SBP, RR, PT, INR, BE, serum albumin, GCS). A P value b 0.05 was considered statistically significant (Table. 1). Then we compared the RTS, RTS-A, EMTRAS and BIG score with in-hospital mortality by re- ceiver operating characteristic curve (ROC curve) [3].

There were 113 cases were enrolled in the study, among which 76 were male and 37 were female. Other basic data could be found on Table 1. The AUC (Area under ROC Curve) of these scores (RTS, RTS-A, BIG and EMTRAS) were respectively 0.914(P = 0.000, CI 0.845-0.959), 0.923(P = 0.000, CI 0.871-0.976), 0.937(P = 0.000, CI 0.881-0.993)

and 0.833 (P = 0.762, CI 0.747-0.920) (Table 2), but there was no sta- tistically difference between RTS-A and RTS (Table 3). RTS, RTS-A were negatively correlated with the death (P = 0.000, P = 0. 000). While BIG and EMTRAS was positively correlated with mortality (P = 0.000 and P = 0.000) (Fig. 1).

https://doi.org/10.1016/j.ajem.2017.07.071

Table 1

Baseline characteristics of Severe trauma patients (n = 113).

20 May 2017

Mean

Standard deviation

Median

P25

P75

p

value

Age (years)

45.7

19.341

0.312

SBP (mm Hg)

123

106.5

134

0.05

RR

21

20

23.5

0.009

GCS

15

8.5

15

0.000

PTINR

1.05

0.97

1.13

0.000

PTPERCENT (%)

106

84

134

0.000

Base excess (mmol/L)

3.78

1.31

6.40

0.000

Albumin (gram/deciliter)

3.665

0.716

0.000

ISS

25

17

36.50

0.000

RTS

12

10

12

0.000

RTS-A

48.40

42.35

52.85

0.000

EMTRAS

8

7

9

0.000

BIG

7.6575

4.8125

13.305

0.000

Mortality (%)

18.4

References

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  2. Vestbo J, Hurd SS, Agusti AG, Jones PW, Vogelmeier C, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary dis- ease: GOLD executive summary. Am J Respir Crit Care Med 2013;187(4):347-65. https://doi.org/10.1164/rccm.201204-0596PP.
  3. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008;34:17-60. https://doi.org/10.1007/s00134- 007-0934-2.

    P25, 25% percentile; P75,75% percentile; SBP, Systolic Blood Pressure; RR, Respiratory Rate; GCS, Glasgow Coma Scale; ISS, Injury Severity Score; RTS, Revised Trauma Score; RTS-A, Revised Trauma Score plus serum albumin; EMTRAS, Emergency trauma Score; BIG, Ad- mission Base deficit, International normalized ratio, and Glasgow Coma Scale.

    Correspondence / American Journal of Emergency Medicine 36 (2018) 319338 333

    Table 2

    Area under receiver operating characteristic curves of the four trauma scores.

    AUC

    SE

    95% CI

    p value

    RTS

    0.914

    0.037

    0.842-0.986

    0.000

    RTS-A

    0.923

    0.027

    0.871-0.976

    0.000

    BIG

    0.937

    0.0285

    0.881-0.993

    0.000

    EMTRAS

    0.833

    0.044

    0.747-0.920

    0.000

    Table 3

    Differences between ROC curves of four trauma scores.

    Conflict of interest

    The authors declare no conflicts of interest.

    Di Hao, MD Hai, Hu, MD Liyuan, Peng, MD Maoni Zeng, PhD Peng Yao, MD

    Jie Zhao, MD Yu Cao, PhD*

    BIG and RTS-A RTS-A and RTS RTS and EMTRAS

    Difference between areas 0.0139 0.00917 0.0808

    P value 0.6732 0.7296 0.1123

    RTS is a physiological score for predicting in-hospital mortality and outcome of traumatic patients and is used widely over the world. More- over it can correctly identified N 97% of nonsurvivors as requiring trauma center care [4] [5]. In our study we use RTS, RTS-A, BIG and EMTRAS to evaluate in-hospital mortality of patients with severely trauma. It’s showed that the value of the RTS plus serum albumin (RTS-A) and the original RTS have equal value in predicting the in-hospital mortality of severe trauma patients. Given more simple and cheap than other scores, we think RTS is better. Of course, our pilot study was restricted by its ret- rospective study design, missing data and small sample size. Next, we will do more works on all.

    In conclusion, RTS plus serum albumin (RTS-A) can indeed predicts the in-hospital mortality of trauma patients. But to those severely injury patients, the RTS has the same discriminatory power compared with the RTS-A. Due to the easy availability and low-cost, we recommend to using the original RTS to triage patients with severe trauma.

    Acknowledgement

    This work was financially supported by the Special Science Founda- tion for Public Interest of Ministry of Health (No. 201302003).

    Department of Emergency Medicine, West China Hospital, Sichuan

    University, Chengdu, China

    *Corresponding author at: Department of Emergency Medicine, West China Hospital, Sichuan University, 37 Guoxue Road, Chengdu 610041,

    Sichuan, China.

    E-mail address: [email protected] (Y. Cao)

    14 July 2017

    https://doi.org/10.1016/j.ajem.2017.07.072

    References

    Kim Seong Chun, Kim Dong Hoon, Kim Tae Yun, Kang Changwoo, Lee Soo Hoon, Jeong Jin Hee, et al. The Revised Trauma Score Plus Serum Albumin level Improves the Pre- diction of Mortality in Trauma Patients; 2017. https://doi.org/10.1016/j.ajem.2017.06. 027.

  4. Baltazar GA, Pate AJ, Panigrahi B, et al. Malnutrition as measured by albumin and prealbumin on admission is associated with poor outcomes after severe traumatic brain injury. Am Surg 2015;81(2):E61.
  5. Lett RR, Hanley JA, Smith JS. The comparison of injury severity instrument perfor- mance using likelihood ratio and ROC curve analyses[J]. J Trauma 1995;38(1):142-8.
  6. Champion HR, Sacco WJ, Copes WS, et al. A revision of the trauma score. J Trauma 1989;29(5):623-9.
  7. Yousefzadeh-Chabok S, Hosseinpour M, Kouchakinejad-Eramsadati L, Ranjbar F, Malekpouri R, Razzaghi A, et al. Comparison of revised trauma score, injury severity score and trauma and injury severity score for mortality prediction in elderly trauma patients. Ulus Travma Acil Cerrahi Derg 2016 Nov;22(6).

    Fig. 1. ROC curve of these 4 scores (RTS, RTS-A, BIG, EMTRAS) predicting mortality of severe trauma patients.

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